How to Document Diverticulitis with ICD-10 Codes

How to Document Diverticulitis with ICD-10 Codes

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Diverticulitis is the most serious type of diverticular disease that primarily affects the large intestine (bowel). This condition occurs when small pouches/sacs (called diverticula) form in the wall of the large intestine/colon and push outward through the weak spots in the colon wall. When these pouches become inflamed or get infected (with bacteria) that condition is known as diverticulitis. Severe abdominal pain, fever, nausea and change in bowel habits are some of the most common symptoms. Diagnosis by an expert gastroenterologist is crucial for effectively treating this digestive disorder and reducing the associated symptoms.

Medical coding outsourcing services can help gastroenterology specialists ensure accurate and timely claim filing and reimbursement.

Most individuals will have a number of diverticula (small pouches in the intestine wall).

When the diverticula are not infected or inflamed, the condition is called diverticulosis.

When diverticulosis is associated with inflammation and infection it is called "diverticulitis."

Reports suggest that around 50 percent of people may develop diverticulosis by the age of 50 years. Around 10 to 25 percent of people with diverticulosis will go on to develop diverticulitis. The condition often requires treatment because it typically causes severe symptoms that can lead to serious health complications.

What Are the Symptoms of Diverticulitis?

The signs and symptoms of diverticulitis can range from mild to severe. These symptoms can appear suddenly, or occur slowly over a few days. Pain in the abdomen is one of the most common symptoms, which typically occurs in the lower left side of the abdomen.

Some of the other symptoms include 

Pain, which may be constant and persist for several days



Nausea and vomiting



Fever



Abdominal tenderness



Constipation or, less commonly, diarrhea



Increased urge to urinate (urinating more often than usual or burning sensation while urinating)



Rectal bleeding

While there are several risk factors for this digestive disorder, the key risk factor is age. The condition is very common among older adults, especially those above the age of 60 years.

Other potential risk factors include - obesity, lack of physical exercise, smoking, medications and diet high in animal fat and low in fiber.

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Diagnosis and Treatment Diverticulitis can be difficult to diagnose because abdominal pain is a symptom of many digestive disorders. As abdominal pain can indicate a number of other problems, physicians may conduct a number of other tests to rule out other causes for your symptoms. Initial diagnosis will begin with a detailed evaluation of health history, symptoms and routine physical examination (including checking your abdomen for tenderness). A digital rectal exam will be conducted to check for bleeding, pain and other issues. In addition, for women, a general pelvic examination will be done to rule out pelvic disease.

Several diagnostic imaging tests such as abdominal ultrasound or abdominal CT scan (to get pictures of your gastrointestinal tract), and liver function tests will be performed. In addition, pregnancy tests in women and blood and urine tests (to check for infections, inflammation and anemia) will be conducted.

Treatment modalities for this condition may depend on the type and severity of symptoms.

Mild symptoms may be treated using antibiotics such as metronidazole (Flagyl, Flagyl ER) or amoxicillin and over-the-counter medications like acetaminophen (Tylenol), to reduce the level of discomfort. A short-term clear liquid diet and a low fiber diet may be recommended to reduce the symptoms. Complicated diverticulitis treatment generally involves intravenous antibiotics and insertion of a tube to drain an abscess (if one has formed). Surgical procedures like primary bowel resection and bowel resection with colostomy will be opted only as a last resort for severe or recurring diverticulitis.

Gastroenterologists who treat diverticulitis are required to maintain clear and complete documentation regarding their diagnosis and the medical services provided. General surgery medical coding involves using specific ICD-10 diagnosis codes for reporting diverticulitis on the medical claims.

ICD-10-CM codes used to indicate a diagnosis of diverticulitis for reimbursement purposes include – K57 Diverticular disease of intestine K57.0 Diverticulitis of small intestine with perforation and abscess •

K57.00 Diverticulitis of small intestine with perforation and abscess, without bleeding

•

K57.01 Diverticulitis of small intestine with perforation and abscess, with bleeding

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K57.1 Diverticular disease of small intestine without perforation or abscess •

K57.10 Diverticulosis of small intestine without perforation or abscess without bleeding

•

K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding

•

K57.12 Diverticulitis of small intestine without perforation or abscess without bleeding

•

K57.13 Diverticulitis of small intestine without perforation or abscess with bleeding

K57.2 Diverticulitis of large intestine with perforation and abscess •

K57.20 Diverticulitis of large intestine with perforation and abscess, without bleeding

•

K57.21 Diverticulitis of large intestine with perforation and abscess, with bleeding

K57.3 Diverticular disease of large intestine without perforation or abscess •

K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding

•

K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding

•

K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding

•

K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding

K57.4 Diverticulitis of both small and large intestine with perforation and abscess •

K57.40 Diverticulitis of both small and large intestine with perforation and abscess, without bleeding

•

K57.41 Diverticulitis of both small and large intestine with perforation and abscess, with bleeding

K57.5 Diverticular disease of both small and large intestine without perforation or abscess •

K57.50 Diverticulosis of both small and large intestine without perforation or abscess without bleeding

•

K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding

•

K57.52 Diverticulitis of both small and large intestine without perforation or abscess without bleeding

•

K57.53 Diverticulitis of both small and large intestine without perforation or abscess with bleeding

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K57.8 Diverticulitis of intestine, part unspecified, with perforation and abscess •

K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess, without bleeding

•

K57.81 Diverticulitis of intestine, part unspecified, with perforation and abscess, with bleeding

K57.9 Diverticular disease of intestine, part unspecified, without perforation or abscess •

K57.90 - Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding

•

K57.91 - Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding

•

K57.92 - Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding

•

K57.93 - Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding

Medical coding for diverticulitis is challenging. For accurate and timely medical billing and claims submission, general surgery practices can outsource their medical coding tasks to a reliable medical billing company that provides the services of AAPC-certified coding specialists.

Diverticulitis

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Incorporating several systematic positive lifestyle habits such as regular exercise, drinking plenty of fluids and eating more fiber rich foods can reduce the potential risk of developing this condition or help reduce the symptoms, or risk of recurrence. People who consume a well-balanced diet with plenty of fruits and vegetables will have a reduced risk of developing diverticulitis.

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